Download - Kuliah Thorax Paru
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Oleh
dr Lilis S, SpRad
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PendahuluanRo Thorax - pemeriksaan penting pd peny. Paru,
Jantungtambahan: costae, vertebra, clavicula, scapula, soft tissue
- Pemeriksaan rutin secara massal : check up calon siswa/pegawai
- Sarana dokumentasi dan follow up yang obyektif
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Macam-macam foto thorax Thorax PA ideal Thorax PA duduk Thorax AP pasien tidak bisa berdiri Thorax lateral kanan/kiri Untuk evalusi paru dan jantung
Khusus : Kondisi tulang mis: Thorax PA kondisi
tulang Kondisi soft tissue
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Thorax PA
Thorax lateral kiri
FILM
FILM
SINAR
SINAR
ANT
ANT
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Pembacaan foto Ro yang baik :- Perlu latihan
- Pengetahuan anatomi thorax
- Koordinasi antar bagian : klinisi, laboratorium, radiologist
keterangan klinis harus ada gambaran radiologi sama evaluasi post terapi foto lama disertakan
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Pembuatan foto yang baik1. Identitas pasien : nama, sex, umur, alamat,
(sebisa mungkin tercetak)
2. Posisi : simetris, semua lapang paru terlihat, - Scapula tidak menutupi lapang paru- Corpus vertebra terletak di tengah
3. Kualitas : Kv, mAs gambar tajam- Kondisi sinar baik di luar cavum thorax
cukup hitam
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Marker R atau L Inspirasi Cukup ( costa VI ka dpn
potong hemidiafragma ka 1/3 medial )
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Foto thorax memperlihatkan :- Costa
- Diaphragma- Jantung- Paru- Scapula- Clavicula- Jaringan lunak dinding thorax
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Cara evaluasi foto Thorax
Dari luar ke dalam kulit ke jantung/paru
Atau
Dari dalam ke luar jantung/paru ke kulit
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Cara evaluasi foto Thorax
Jaringan lunak : kulit, subcutan, musc.Pectoralis major, trapezius, sternocleidodeus
Tulang : cervical bawah s/d VTh3, scapula, clavicula, humerus atas, costa
Diaphragma : kanan > tinggi dr kiriPertengahan costa 6/7 kanan depan potong
pertengahan hemidiaphragma kanan
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Parenchym paru Sinus phrenicocostalis (sudutx tajam) Hylus, bronchovascular Mediastinum Jantung
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Syarat thorax n batas jantung
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Pemeriksaan Jantung
Bentuk jantung / mediastinum . Ukuran jantung . Keadaan pembuluh darah besar . * Aorta . * Arteria pulmonalis dan
vascularisasi paru . Keadaan paru. Bentuk dipengaruhi bentuk badan
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Ukuran Jantung
Cardio-thoracic ratio : Diameter terlebar jantung : diameter terlebar dinding dalam thorax {A+B:C1+C2}.
Normal < 0,50/0,54
Arcus Aorta :D+E < 4 cm
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Aorta knob : dari grs tengah ketepi kiri AO : E < 2 cm
Batas jantungkanan A < 1/3 C1 kiri B< ½ C2
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UKURAN JANTUNG
CTR : normal : 45-54 % Ratio ini tidak selalu bermakna patologis. Batas kanan : A < 1/3 C1 Batas kiri : B < ½ C2 Normal batas atas Arcus Ao < 1-2 cm
dari manubrium sterni Batas bawah : sulit ditentukan karena
tertutup lengkungan diaphragma
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COR / JANTUNG- Thorax PA berdiri, inspirasi cukup- Batas kanan jantung
- Atrium kanan : - Membesar bila : batas kanan bergeser ke
lateral : - Batas kiri jantung
- Ventrikel kiri : - Membesar bila bergeser kekiri
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Lobus paru
Kanan 3 lobus lobus superior (3 segmen) medius (2 segmen)
inferior (4 segmen)Kiri 2 lobus
lobus superior (4 segmen) lobus inferior (4 segmen)
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Tuberculosis paru
Px Ro perlu utk Dx paru pd :1. Klinis TB paru kelainan pada Ro (+)2. Klinis : persangkaan TB Ro(-) :
tanda TB (-)3. Ceck Up : Ro: TB (+), klinis (-) bukan
berarti tdk ada TB 4. Sputum (+)
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Kelainan pd Ro tdk berarti TB aktif Tanda 2 TB aktif P: bercak-bercak,
awan-awan,cavitas Tidak aktif : fibrosis , kalsifikasi Dx pasti : kombinasi klinis/laboratoris
Penilaian tindakan terapi Evaluasi terapi : perbaikan/ + buruk
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Klasifikasi TB Menurut American Tuberculosis Association
1. TB minimal ( minimal TB ) - Densitas ringan – sedang- tdk melebihi garis median, apeks, costa 2 depan- Cavitas (-)
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2. TB Lanjut sedang (Moderately advance TB)
- Infiltrat densitas ringan-sedang , dengan luas tidak lebih dari satu
paru- Densitas berat : Tdk lebih 1 lobus- Cavitas < 4 cm
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3. TB sangat lanjut ( Far advanced TB )- Luas area yg terkena lebih luas dr.
klasifikasi 2- Cavitas > 4 cm
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Gb. 2.34
Laki-laki 34 th. Beret badan turun, keringat malam, PPD test (+)t
Infiltrat /Konsolidasi lobus kanan atas
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Gb. 2.36 TuberculomaNodul soliter lobus sup. kanan dgn.
calsifikasi Fibrosis menarik hilus
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Gb. 2.31 TBC miliarPr. 43 th. dgn. keluhan BB turun & keringat malamNodul miliar tersebar dikedua paru
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Radang Paru Tidak Spesifik
1. Radang bronchus- Berkaitan dg ISPA- Gambaran ro : tdk spesifk- Corakan ramai di basal paru
- Corakan peribronchial bertambah
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2. Radang paruEtiologi : bakteri,virus,protozoa,jamur, bahan kimia, lesi kanker, radiasi ion
Mis. : - Pneumonia - Abces paru
Ro : gambaran konsolidasi radang - tampak perselubungan
- melibatkan sebagian atau seluruh
lobus
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PNEUMONIA lobar pneumonia
Merupakan infeksi parenchim paru Penyebab : bakteri, mycoplasma, virus jamur Bisa disebabkan aspirasi pneumonia
chemical Ditandai dgn. serofibrinous , exudate
cel- lular dlm. Interstitium & alveolar space Mengenai 1 atau lebih lobus
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Pneumonia pada segmen apicoposterior lobus sup. KiriLat : batas bwh konsolidasi oleh fissura mayor(1) Tenting diaphragma kiri(2) Fissura major kanan(3) Fissura major kiri
Airbronchogram gmbrn udara d bronchus
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Pneumonia lobus medius kanan79 th dgn. Peny. Arteri koroner Pleura efusi kanan minimal
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2. Abces paru:Peradangan paru jaringan nekrosis dg pengumpulan nanah
Ro : Cavitas / multicavitas berdinding tebal
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Bronchiectasis
Keadaan bronchus dan bronchiolus yang melebar akibat hilangnya elastisitas otot bronchusCausa : -obstruksi
- Peradangan kronis- Kelainan kongenital
Ro : - Bronchovascular kasar- Honeycomb appearens
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Honeycomb appereans
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Pleura dan MediastinumPleura
- Pleura viseralis- Pleura parietalis
Ro : Normal : tidak tampak Kelainan :
- Efusi pleura- Udara dalam rongga pleura
(Pneumothorax- Infeksi (pleuritis )- Tumor pleura
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1. Efusi pleura Dapat berupa : - Cairan transudat
- Cairan eksudat - Cairan darah - Cairan getah
bening
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Pocket pleural efusion
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2. Pneumothorax: Udara dalam rongga pleuraa. Pneumothorax spontanb. Akibat luka tusuk c. Melalui mediastinum d. Udara dari subdiaphragma : robekan
lambungRo : - Radiolusen disekitar jaringan paru
yang kolaps
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Emphisema
: Keadaan paru yang lebih banyak berisi udara ukuran paru bertambah
1. Emphisema obstruktif- Akut- Kronik- Bulous
1. Emphisema non obstruktif- kompensasi- Senilis ( postural )
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Gambaran Ro:- Thorax kyphosis- Penambahan ukuran paru vertical diaphragma letak rendah- Bayangan lebih radiolucent
- Sela iga melebar
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Atelektasis
: PAru/Sbg paru mengalami hambatan berkembang secara sempurna aerasi berkurang / tdk terisi udara
Causa :1. Bronchus tersumbat2. Tekanan ekstrapulmonar
- Pneumothorax- Cairan pleura- Peninggian diaphragma - Herinasi organ abdomen ke cavum thorax- Tumor intra thorax, ekstrapulmonar
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3. Paralisis/ paresis gerak pernafasan mis : - poliomielitis, kelainan
neurologik4. Hambatan gerak pernafasan karena
- kelainan pleura- trauma thorax
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3. Penebalan pleuraCausa : penyakit pleura menahuan
pneumothorax berulang
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4. Tumor pleura: Lipoma,fibroma,hemangioma,,
neurofibroma- Mesotelioma : tumor primer ganas
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Tumor Mediastinum
Tumor-tumor yang sering dijumpai ;1. Mediastinum superior :
struma,kista bronchogenik,adenoma paratiroid, limfoma
2. Mediastinum anterior :Struma,thymoma,teratoma,adenoma paratiroid,limfoma,lipoma,fibroma,limfangioma,hemangioma dan hernia morgagni
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3. Mediastinum mediusKista bronchogenic, limfoma, kista pericardium, aneurisma, hernia
4. Mediastinum posteriorTumor neurogenik, fibrosarkoma,limfoma, aneurisma, kondroma, meningkel, hernia bochdalek
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Tumor Paru
Pemeriksaan radiologik- Bronchografi- CT Scan- Thorax PA / laterala
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Ro Thorax : Tumor (-) Kelainan sebagai akibat adanya tumor :- Atelektasis- Pembesaran hylus unilateral- Emfisaema lokal- Pelebaran mediastinum- Pneumonitis yang sukar sembuh- Cavitas atau abces yang soliter- Efusi pleura- Elevasi diaphragma- Perselubungan dengan destruksi tulang
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Metastase Paru
- Penyebaran ke paru : - hematogen - limfogen- Gambaran Ro : - tunggal ( soliter ) - Ganda ( multiple )
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Konvensional :1. Foto thorax PA2. Foto thorax lateral3. Foto thorax RAO, LAO4. Fluoroscopy
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Canggih : M. R. I
Nuclear Medicine CT Scan
Angiocardiography Echo Cardiography
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Pemeriksaan Jantung
1.Bentuk jantung / mediastinum . 2.Ukuran jantung . 3.Keadaan pembuluh darah besar . * Aorta . * Arteria pulmonalis dan
vascularisasi paru . 4. Keadaan paru.
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Bentuk jantung/Mediastinum 1 , Usia : - Bayi : relative besar – membulat .2 . Pernafasan : - Inspirasi : diafragma turun => mediastinum memanjang kebawah. - Expirasi :diafragma naik => mediastinum mebulat
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Bentuk jantung/Mediastinum 3.Posisi penderita : - Erect : memanjang – Recumbens :
pendek 4.Bentuk tubuh : - Atletic : memanjang langsing .
- Asthenic : lebih pendek ,- Picnic : membulat
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Bentuk jantung/Mediastinum 5.Jenis kelamin :
Laki : lebih ramping , wanita : pinggang jantung lebih menonjol ,.
6.Keadaan paru .Emphysema : tear drop ,
Effusion : terdorong .Schwarte : tertarik ,
7.Kelainan dinding thorax .
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Ukuran Jantung.
Cardio-thoracic ratio : Diameter terlebar jantung dibanding diameter terlebar dinding dalam thorax {A+B:C1+C2}.Normal < 0.5.
Arcus Aorta :D+E < 4 cm Aorta knob : dari grs tengah ketepi kiri
AO : E < 2 cm Batas kanan : dari grs tengah: A < 5cm A < 1/3 C1, B< ½ C2
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PEMBESARAN JANTUNG Ctr : normal : 45-50 % Ratio ini tidak selalu bermakna patolo- gis. Batas kanan : A < 1/3 C1 Batas kiri : B < ½ C2 Batas atas Arcus Ao < 1-2 cm dari
manubrium sterni Batas bawah : sulit ditentukan karena
tertutup lengkungan diaphragma
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Keadaan normal jantung Proyeksi PA :
Batas kiri jantung dibentuk oleh ventricle kiri , conus pulmonalis , arcus Aortae .
Batas kanan oleh Atrium kanan – hilus pa-ru kanan – vena Cava superior .
CTR : < 0,5 . Pinggang jantung laki2 lebih cekung ,
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Keadaan normal jantung Posisi Lateral :
Dada kiri menempel pada film , Ventricle kanan merupakan bag.
terdepan. Normal menyinggung kurang 1/3
sternum. Bayangan jantung belakang dibentuk
oleh v.Cava inferior => vent kiri=>atrium kiri= > a. Pulmonalis . => Arcus Aorta .
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Pembesaran jantung
Ventrikel kanan : Dinilai dari inflow tract dan out flow tract Inflow tract : membesar ke depan dan
memutar ke kiri. Outflow tract : pinggang jantung
mendatar/menonjol. Pembesaran bisa karena
hipertrofimisal pada PS
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Pembesaran Jantung Ventricle kiri :
Batas kiri membulat melebar kekiri bawah menekan diafragma ( PA ).
Posisi LAO 60o batas belakang melebihi batas depan columna Vertebralis , 45o
mele-bihi batas belakang . Lateral batas belakang bergeser
kebelakang. RAO seluruh jantung mendekati
Vertebra.
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Retro cardiac space
Retro sternal space
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Pembesaran jantung Atrium kiri :
Double contour jantung sebelah Kanan. Pendesakan Oesophagus yg tegas ( RAO ) Biasanya menyertai pembesaran Ventr kiri. Dilatasi Pulmonary arteri terutama kanan . Auricle kiri mebesar pinggang jantung
melurus , bronchus kiri terdorong keatas .
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Atrium kiri
Lateral : - Esofagus terdorong ke belakang ( di isi kontras) - Bila pembesaran prominent dapat
men- dorong jantung ke depan sehingga
overla- pping dengan pembesaran ventrikel
kanan
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Double contour
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Pembesaran jantung Ventricle kanan :
Batas jantung kiri membulat terlihat clear space antara batas kiri dengan diafragma, batas kanan begeser kekanan .
Lateral : menyinggung sternum lebih 1/3. Keseluruhan jantung bergeser kebelakang
seolah olah ventricle kiri mebesar ( pseudo left ventricle hypertrophy ).
Biasanya disertai pembesaran Atrium kanan .
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Pembesaran auricle kiri ikut mmbntuk pinggang jantung
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Pembesaran jantung Atrium kanan :
Pembesaran isolated jarang , biasanya menyertai pembesaran Ventricle kanan .
Batas kanan mebulat bergeser kekanan .
Diafragma kanan terangkat oleh adanya bendungan pada liver .
RAO tampak “ Squaring off ” dari Right appendage
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Pulmonary Vascular
Meningkat terjadi pada : Active : Left to right shunt :
ASD VSD & PDA. Passive : Dilatasi vena
pulmonalis pada gagal jantung kiri .
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Arteria Pulmonalis Main pulmonary Artery normal Laki2 : 16 mm , Wanita 15mm , cabang I
kearah bawah 11 mm . Pada Pulmonary Hypertension :
dibagian central melebar , perifernya mengecil .
Keadaan extrem terjadi pada Eisenmenger physiology .(left to right berubah menjadi right to left setelah pulmonal hypertensi ).
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Kelainan jantung bawaan A Kelainan letak jantung : 1.Dextro-cardia :bentuk = normal
letaknya di kanan , diikuti oleh situs inversus .
2.Dextroversi :berputar kekanan , ventricle kiri didepan , batas kiri
atrium kiri, ventricle kanan lebih kekanan belakang
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Kelainan jantung bawaan. 3. Mesoversi : Jantung berputar
sedikit , letaknya masih ditengah . Organ2 Abdomen normal.
4. Levo-cardia : jantung normal .
Situs inversus organ2 Abdomen .
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Kelainan jantung bawaan B. Kelainan anatomis : I. Pulmonary Vascular
meningkat : 1. ASD . 2. VSD . 3. PDA . II.Pulmonary vascular menurun : 1. Tetralogy Fallot . 2. Pulmonal stenosis .
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Kelainan jantung bawaan ASD. - Defect pada tingkat atrium
. - Terjadi Volume
overloading pada atrium kanan & ventricle kanan terjadi dilatasi dan Congestie aktif pulmonary artery
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Kelainan jantung bawaan VSD : 1.Defect pada bag musculer :
biasanya kecil, menutup saat contractie.
2. Defect pada bag Membranous : paling sering . 3. Bulbar defect daekat muara
AO/PA 4. Jarang : hubungan Ventr ki
atrium ka
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Kelainan jantung bawaan PDA : - Ductus arteriosus gagal
menutup . - Hubungan : Aorta – A. Pulmonalis
kiri. - Overloading pd circulasi Pulmonal - Ventricle kiri dan atrium kiri mem
besar , ventricle kanan membesar setelah ada pulmonal hypertensi.
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Kelainan jantung bawaan
Tetralogy Fallot : Terdiri dari kelainan2 ; 1. High VSD . 2. Pulmonary Stenosis. 3. Over riding Aorta . 4. Right ventricle
hypertrophy
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Kelainan jantung bawaan Tetralogy Fallot : Bentuk klasik : “ Wooden
shoe “ Bila Pulmonary stenosis
ringan , menyerupai VSD.
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P A.pulmonalis menurun
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Kelainan jantung yg didapat Mitral Stenosis / Mitral Regurgitasi
. Pericarditis / Pericardial effusion . Aorta stenosis / Aorta regurgitasi . Pulmonal stenosis / pulmonal
regurgitasi. Tricuspidal stenosis / regurgitasi .
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Kelainan jantung yg didapat Mitral Stenosis :
Pada keadaan normal aliran darah dari atrium ke ventricle baik kiri ataupun kanan 70% secara pasive , 30% berikut active oleh contraksi atrium .
Stenosis > 25% akan terjadi gangguan Haemodinamic .
tugas active atrium kiri > 30% menyebabkan pembesaran .
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Kelainan jantung yg didapat Mitral stenosis : RO: Atrium kiri membesar . Ventricle kiri membesar
stadium lanjut. Mitral regurgitasi : diatrium
volume overloading saat sistole , pembesaran ventricle kiri untuk mencukupi cardiac out put . ( LA + LV membesar ).
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Pericardial efusi
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